The Role of Health Care Providers in Reducing Prescription Drug Abuse and Overdose Deaths in Los Angeles:
Policy- and Clinic-Level Interventions

Gary Tsai, MD, FASAM, FAPA

May-June 2017

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Prescription drug overdoses are now the leading cause of injury death in the U.S. surpassing deaths from motor vehicle accidents and from gun homicides.1 While the U.S. comprises less than 5% of the global population, it uses 80% of the world’s opioids.2 Years of unimpeded opioid prescribing by physicians has contributed to our national opioid epidemic of addiction, worsened health outcomes, and increased deaths from overdose. Prescription drug abuse has become one of the fastest growing public health concerns in the country and is of particular relevance in primary care settings. The complexity of the opioid crisis requires a culture change in how health care providers and society view and respond to pain and addiction.

This article will highlight both policy and clinical-level interventions for health care providers to reduce prescription drug abuse and overdose deaths in Los Angeles County.

 

Policy-Level Interventions

Be familiar with and support Safe Med LA (www.SafeMedLA.org)

Safe Med LA is a countywide coalition of health professionals working together to reduce prescription drug abuse and overdose deaths in Los Angeles.  As the causes of prescription drug abuse are multifaceted and complex, Safe Med LA has designed a multi-pronged strategy to apply evidence-based interventions in nine key action team areas, which are summarized below.

  1. Safe Prescribing in Medical Practice – Implementing safe pain prescribing guidelines in emergency departments, urgent care centers, medical clinics, and dental practices to reduce over-prescribing, misuse, abuse, and diversion.
     
  2. Safe Prescribing in Pharmacy Practice – Ensuring that pharmacists, who are often the last health professionals to interact with patients prior to them receiving opioids, have the training and tools to support safe prescribing and to furnish naloxone.
     
  3. Medication-Assisted Treatment – Expanding access to medication-assisted addiction treatments such as buprenorphine and long-acting injectable naltrexone.
     
  4. Naloxone Access – Increasing access to naloxone for opioid overdose prevention.
     
  5. Safe Drug Disposal – Decreasing the supply of unused drugs in homes and the community by ensuring access to convenient, safe, and environmentally responsible drug disposal programs.
     
  6. Community Education – Increasing public awareness of the risks of prescription drug abuse. Educating about how to use, store and dispose of drugs safely and how to access local resources for drug treatment and overdose prevention.
     
  7. CURES – Increasing the number of prescribers using California’s Prescription Drug Monitoring Program, known as CURES 2.0. Through CURES, health care providers can identify possible patterns of controlled substance abuse and enhance their prescribing decisions to combat prescription drug abuse.
     
  8. Law Enforcement – Identifying opportunities to educate and train the criminal justice community to better navigate the interface between public health and law enforcement. Collaborating with law enforcement to identify and address improper practices such as indiscriminate prescribing by “pill mills” and inappropriate "doctor shopping".
     
  9. Data Collection – Increasing data collection and information sharing across systems, agencies and organizations to effectively coordinate care and interventions to reduce overprescribing, misuse, and diversion of prescription drugs, while also encouraging treatment.

With the collective impact of successful interventions in these nine areas, Safe Med LA plans to reduce prescription drug abuse deaths in Los Angeles County by at least 20% by 2020. Providers can support Safe Med LA initiatives by sharing information with colleagues, by joining a Safe Med LA action team, as well as by implementing interventions in their practices (see clinic-level interventions below).

 

Clinic-Level Interventions

An estimated 20% of patients presenting to physician offices with non-cancer pain symptoms or pain-related diagnoses (including acute and chronic pain) receive an opioid prescription.3 Prescriptions by primary care providers (PCPs) account for nearly half of all dispensed opioid prescriptions in the U.S. and this prescribing rate continues to grow.4  For this reason, the Centers for Disease Control and Prevention (CDC) created guidelines specifically for PCPs on prescribing opioids for chronic pain.5

Here are several clinic-level interventions recommended by Safe Med LA and/or the CDC to help reduce drug abuse and overdose deaths.

  • Screen patients for substance misuse and talk with them about the need for help, when necessary

    It is estimated that 20-45% of adult patients in primary care have substance use disorders but less than 10% are diagnosed in the primary care setting.6,7

    “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” is a validated single question screening test for drug use in primary care.8

 

Three Key Principles for Prescribing Opioids for Chronic Pain
  1. Use non-opioid therapies (physical therapy, cognitive behavioral therapy and non-opioid medications such as anti-inflammatories).
  1. When opioids are necessary:
    1. Start with the lowest effective dose and increase slowly and judiciously.
    2. Start with immediate-release formulations instead of long-acting opioids, as needed.
    3. Only prescribe enough for the expected duration of pain.
  1. Regularly monitor patients to make sure that the opioids are improving pain and functioning without causing harm.

 

  • Use CURES before prescribing opioids

    Access a patient’s controlled substance history in CURES to identify possible patterns of abuse (e.g. “doctor shopping”) and to inform prescribing decisions.

  • Offer medication-assisted treatment (MAT) for addiction

    MAT such as buprenorphine and naltrexone is an underutilized pillar of addiction treatment. Oftentimes, PCPs are the only health care providers in a position to speak with individuals about the option of MAT for their SUD. Counsel about MAT and refer/prescribe, when appropriate. Importantly, it is highly recommended that MAT be accompanied by psychosocial treatment for SUDs.

  • Offer naloxone for opioid overdose prevention

    Reduce the likelihood of death from an opioid overdose by offering naloxone to at-risk patients [e.g. opioid dose ≥ 50 morphine milligram equivalents (MME)/day, concurrent benzodiazepine use, history of overdose, or with SUD], and to members of their social networks.

  • Encourage and educate patients on safe drug disposal

    More than half of people who have used prescription drugs for nonmedical purposes reported obtaining them from family, relatives, or friends.9 When prescribing pain medication, educate your patients on how to dispose of unused medication safely.

 

Conclusion

Addressing the opioid crisis requires a culture change in how society views pain and what to do when our reliance on painkillers become problematic. Physicians and other health care providers are in a unique and respected position to shape our community’s perspective on how to view and respond to pain. We now know that the message of “zero pain” has contributed to the overuse and misuse of painkillers and needs to be reframed to “functional tolerance”.  Adopting safe prescribing practices across systems and in clinics is a critical step in changing the culture of pain management, as is ensuring that patients have access to medication-assisted addiction treatment to treat active addiction and naloxone to reduce the likelihood of opioid overdose deaths.

The Safe Med LA goal to reduce prescription drug abuse deaths in LA County requires active support from the provider community.  Prescription drug abuse deaths can and will be reduced in Los Angeles County if every health care provider takes action at the clinical and/or policy level. Visit the DPH Substance Abuse and Prevention Control Program website for more local resources for patients and providers.  Health care providers have contributed to the local and national epidemic of prescription drug abuse; now we have the opportunity to be part of the solution.

 

Additional Resources

Los Angeles Referrals for Specialty SUD Treatment

  • Primary care clinics and individuals can initiate a referral or self-referral by calling the Substance Abuse Prevention and Control resource line at (888)742-7900; once the caller has indicated where the person needing SUD treatment lives, they are routed to their local Community Assessment Service Center (CASC).

Screening for SUD

Medication-Assisted Treatment

CDC Safe Prescribing Guidelines

  • At-a-Glance-Guidelines for Prescribing Opioids for Chronic Pain [4 page summary]
  • Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 [full guidelines]

 

 

Assess Monitor Manage - banner for CDC opioid prescribing guideline

 

 

References

  1. Trust for America’s Health. The Facts Hurt: A State-by-State Injury Prevention Policy Report. 2015. http://healthyamericans.org/assets/files/TFAH-2015-InjuryRpt-final6.18.pdf
  2. Manchikanti L. Therapeutic Use, Abuse, Nonmedical use of Opioids: A Ten-Year Perspective, Pain Physician. 2010; 13:401-435.
  3. Daubresse M, Chang HY, Yu Y, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Med Care. 2013;51:870–8.
  4. Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007–2012. Am J Prev Med 2015;49:409–13.
  5. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
  6. Lee J, Kresina TF, Campopiano M, et al. Use of Pharmacotherapies in the Treatment of Alcohol Use Disorders and Opioid Dependence in Primary Care. BioMed Research International. 2015:137020. DOI:10.1155/2015/137020. Epub 2015 Jan 5.
  7. Buchsbaum DG, Buchanan RG, Lawton MJ, Schnoll SH. Alcohol consumption patterns in a primary care population. Alcohol and Alcoholism. 1991;26(2):215–220.
  8. Smith PC, Schmidt, SM, Allensworth-Davies D, Saitz R. A single-Question Screening Test for Drug Use in Primary care. Arch Intern Med. 2010;170(13):1155-1160
  9. Substance Abuse and Mental Health Services Administration (SAMSA). National Survey on Drug Use and Health 2015. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf. Accessed March 16, 2017.
 

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Author Information:

Gary Tsai, MD, FASAM, FAPA

Co-Chair, Safe Med LA

Medical Director and Science Officer, Substance Abuse Prevention and Control

County of Los Angeles
Department of Public Health

gtsai@ph.lacounty.gov

www.safemedla.org

www.publichealth.lacounty.gov/sapc


Rx for Prevention,
2017 May-June;7(1).